Trust told to review 13 deaths after inquest rules man's fatal heart attack could have been prevented
More inquests may be held
A coroner has ordered a Northern Ireland health trust to review 13 deaths after an inquest found that a man's death while on a waiting list could have been prevented.
Denis Doran, a businessman from Lurgan, passed away after suffering a major heart attack, having been wrongly diagnosed with a hernia.
At least four more patients may have died as a result of the 'individual and systemic' failures within the Southern Health and Social Care Trust, a coroner was told.
The health trust revealed that a total of 13 patients passed away while waiting to be referred to the Rapid Access Chest Clinic at Craigavon Area Hospital in 2016.
The shocking statistic was only disclosed moments before the coroner made his findings on the circumstances surrounding the death of Denis Doran (57) in Belfast yesterday afternoon.
Consultant cardiologist Dr Michael Moore was unable to confirm if anyone on the waiting list had died when he gave evidence on Tuesday - the information was forwarded to the Coroner's Service on Thursday evening.
Coroner Patrick McGurgan has ordered the Trust to conduct a review into all 13 cases.
Mr Doran, known as Denny, arrived at hospital with chest pains on August 29, 2016, but was wrongly diagnosed with a hiatus hernia by a locum consultant, who failed to recognise textbook symptoms of a cardiac problem.
The popular singer suffered a massive heart attack two months later while at home with his wife Yvonne (60).
Earlier this week the inquest was told that the patient was given wrong assurances after he began complaining about chest problems, which meant he did "arm stretches" to relieve hernia symptoms instead of seeking urgent medical attention on the night he died.
Dr Mohammod Asaduzzeman, known as Dr Asad, admitted that he may not have read his patient's notes before he misinterpreted an "abnormal" ECG as "normal" before Mr Doran was discharged.
It later emerged that the Bangladeshi-born doctor was made a locum consultant "almost overnight" despite being deemed "not suitable" to be appointed as a standard consultant within the NHS.
The inquest was also told that Dr Asad graduated medical school in his home country before further training in Saudi Arabia. While he had worked in a number of hospitals in England, he had held "no substantive" post in the UK.
Dr Asad also admitted he was "not aware" of the existence of the Rapid Access Chest Pain Clinic as "there was no formal orientation process" for locums.
Mr Doran had been referred to the clinic, which has a two week waiting list target, on two occasions by his GP, but he died before his appointment, which he was told would take 11 weeks. Yesterday, the coroner accepted that this contributed to Mr Doran's death, as it emerged that six of the 13 other deaths around the same period were cardiac-related.
Four patients died after being forced to wait for longer than the two week target.
One patient had been on the list for three months and another for two months when they died.
Two patients died after waiting for almost a month.
Coroner Patrick McGurgan said the outcome for Mr Doran would have been different if he had been properly diagnosed and given necessary treatment.
He also said his death could have been prevented if he had been seen within a timely manner by a cardiologist in the chest clinic.
Mr McGurgan has ordered the Southern Health and Social Care Trust to conduct a review of all 13 individuals who died while on the waiting list - he also indicated that more inquests could be required to determine the circumstances surrounding the deaths.
The inquest previously heard how a junior doctor believed Denny's chest pains were heart-related, but felt that she couldn't challenge Dr Asad, who was a more senior medic, and who she falsely believed to be a cardiologist.
Dr Asad broke down and wept as he admitted making a serious human error.
"I'm sorry," he told Mr Doran's widow and two children.
"I know I made a mistake, but it was not my intention.
"I cannot change what happened. I did it, but I have learned from it.
"I've done my best to go through the process to make sure it never happens again."
Yesterday, a spokesperson for the trust offered "deepest sympathies" to the Doran family and promised to review the coroner's written findings, "along with our own internal investigations". The spokesperson added: "We have fully participated in this inquest process and accept the coroner's findings."
However, Mr Doran's heartbroken widow expressed her fear that the Southern Trust will "only pay lip service" to her devastated family as she vowed to personally scrutinise the progress of the review.
"I'm not dropping this, because they have dragged their heels before," she said.